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Cranio-maxillofacial

Implant Directions®
Vol.2 No.3 September 2007
ISSN 1864-1199 / e-ISSN 1864-1237

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Basal implants: A safe and effective
treatment option in dental implantology

Published by IF Publishing, Germany


Full Length Article other patient or implant related characteris-
Basal implants: A safe and effective tics were found to be associated with a failure
treatment option in dental implantology rate over 7%. The clinical application of basal
implants is safe and effective and useful in a
Dr. Sigmar Kopp broad range of indications with immediate load-
Niklotstr. 39 ing protocols and without the need for invasive,
DE-18273 Güstrow costly, and time consuming bone augmentation
sigmar.kopp@implantfoundation.org procedures.

Abstract Keywords
The purpose of this four years study was to Basal implants, implant survival, immediate
report on the outcomes after using a basal loading, poor bone, BOI, basal implants
implant design for treating patients espe-
cially with poor quality and quantity of bone Introduction
under immediate load conditions. From May Survival rates for conventional dental implant
2003 to end of April 2007, 88 consecutive systems are relatively high in normal healthy
patients receiving 302 BOI®-implants were bone.1 However, there are subgroups of pa-
enrolled in this study. No patients seeking tients that are at an increase risk of implant or
implant treatment were turned away for treatment failure. In particular, patients with re-
any reason nor got screw type implants. duced quantity or quality of bone present a sig-
The mean age at implant surgery was 50.1 nificant challenge to the dental implantologist
years. All 88 patients and their implants and have higher rates of implant failure (2-6).
were accounted for at the end of the follow- Disease, congenital anodontia, trauma, or atro-
up period. All but one implant underwent phy due to the aging process leads to this poor
immediate loading. Even in cases of severe quality or quantity of bone.
bone atrophy, no augmentations were per-
formed. We found a 95.7% implant survival A lack of physiological forces in fully- or partially
rate among this consecutive group of pa- edentulous patients often leads to a decrease
tients with varying degrees of bone quality in the residual alveolar ridge. Dental implants
and quantity. All patients received a fixed may help to preserve bone due to their positive
temporary or permanent bridge within 24 load-related effects on the jawbone surrounding
hours after the implant procedure. All pa- the implant; hence, appropriate solutions should
tients continued to possess fixed dentures, be explored and discovered to facilitate this pro-
so the prosthetic outcome is 100%. Basal cess in these challenging patients (7,8).
implants used for single tooth replacement The management of poor bone with root-
showed the lowest survival rate (90.9%), form dental implants typically requires additional
but this was result of specific overload. No or augmentative procedures to ensure sufficient

110
stability, even if there are newer developments Implants
like Osseopore®, a short conical implant design Titanium basal implants consist of a cylindrical
with sintered surface. Most of these short verti- part and a larger, cortically anchored base plate.
cal integrated implants require a long function- Unlike the traditional root-form implants (i.e.,
less healing period. Bone augmentation may be screw and blade implants), which are inserted
necessary through procedures such as grafting, vertically and primarily designed to be supported
transplanting, or more novel therapies includ- by trabecular bone, these implants are inserted
ing augmentation of bone combined with substi- from the lateral aspect of the host bone provid-
tutes and/or morphogenetic proteins (9). So all ing multicortical support. Hence, are common-
these methods typically add treatment steps to ly called “disk” or “lateral” or “basal” implants.
the procedure, delay loading, and increase the BOI® implants possess one to three very pro-
total risks and costs. nounced „threads“ or “base-plates”, which are
securely anchored in the cortical bone, a bone
With basal implants (BOI®-brand of Dr. Ihde area which is more stable during the remodel-
Dental AG, Switzerland) we avoid augmentation ing/resorption process and which can respond
and reopening, have immediate function and successfully to immediate loading protocols,
generally do implantation simultaneously with Figures 1, 2, 3. BOI® implants allow for the fa-
the extraction, so these advantages make a vorable distribution of masticatory loads to the
study expedient. cortical regions. The site of force transmission
is far away from the site of bacterial invasion al-
Methods lowing for early loading and resistance to infec-
Subjects tion. This, as well as the thin smooth shaft, may
be a reason for their observed and reported
From May 2003 to April 2007, 88 consecutive equal success in smokers as in non smokers.
patients (55.7% female) receiving 302 basal im-
plants (mean = 3.4 per person; SD=2.8; median While we used 11 different implant types in
= 2.0: range, 1 – 16) and 129 prosthetic con- this series of patients with varying shaft lengths,
structions thereon were enrolled in this study. they can be basically categorized in two major
All patients seeking implant treatment have groups: BOI® with single base plates and more
been treated by BOI® only and included in the than one base plate (up to three). The majority
study. The surgical and prosthetic treatments of the patients who received a single disk were
were all performed by the same clinician. The those with poor available vertical bone especial-
mean age at implant surgery was 50.1 years ly in the distal jaws. But the atrophic bone in this
(SD=14.1; range: 16 to 80 years). area is frequently broad, which is ideal indication
for basal implants due to their lateral placement,
Figures 2-5. In a few cases (N=12; 4%), the re-
sidual cavities after teeth or implant displace-

CMF.Impl.Dir. Vol 3-2007 111


ment were so large, that it seemed appropriate of extracted teeth or crestal and basal implants
to fill them with synthetic material (Nanobone® (N=20; 6.6%). Of all implants 156 (51.7%) were
- brand of Artoss® GmbH, Germany). single disks and 146 (48.3%) were multiple
disks (> 1 disk). Shaft height used was primar-
Data Analysis ily 8mm (58.6%). Due to our broad inclusion
Descriptive statistics were calculated for base- criteria, we placed between 1 and 16 per pa-
line variables. The primary outcome of interest tient (Mean= 3.4; Median=2), but no more than
was implant failure defined as any reason for 8 each jaw. Prosthetic classes included single
having to remove an implant. Survival was based crowns, linear bridges on teeth and implants,
on the period from implant placement to final or on implants only, as well as circular bridges
follow-up. Because BOI® implants are immedi- on mostly four implants. With the exception of
ate load implants, it was not possible to distin- one implant which underwent closed healing,
guish between a “healing” phase and a “loading” remaining implants (99.7%) were loaded imme-
phase and especially in circular restorations diately or within the first 24 hours after the im-
all implants were loaded under full masticatory plantation. Fixation of the permanent prosthetic
loads. All failures were counted immediately if construction followed after surgery (Mean=47;
they were observed. The log-rank test was used SD=30.6; Median=44; range 0-156 days). Thir-
to test statistical significance comparing sur- teen implants failed (Mean=391; Median=432;
vival rates among risk factors. SD=273; range 41- 841 days) during the fol-
low-up period giving an overall survival rate of
Results nearly 96%.
Patients were followed for a mean of 637 The survival curve for the entire series of im-
days (Median=540; SD=427; range: 27 - 1472 plants is shown in Figure 6. Survival rates strati-
days). Because we found the highest loss rate fied by different factors are shown in Table 1.
in the first days (~4.4% when including the first The number of base plates induced a significant
month and up) and to show the tendency in sur- (p<0.05) difference in survival rates of 1.7%.
vival rates, we included the youngest cases with Only in the single crown group a higher but non-
short follow up time. The survival rate increas- significant failure rate was observed (9.1%).
es by time in situ up to 100% for three years There were no implant failures in the implant
and more. None of the patients disappeared groups longer than three years in situ set sub-
or dropped out of the series reported here for nasal used in combination with Nanobone®, or
any reason. Of the 302 implants, 162 (53.6%) when fixed horizontally by bone screws, Table
were placed in the upper jaw and 140 (46.4%) 1.
in the lower jaw. Subantral, the distal lower jaw
and often subnasal are regions with poor bone. All patients in this series continue to maintain
Here were 189 (62.6%) implants inserted. 157 healthy fixed crowns or bridges giving a pros-
implants (52%) were inserted into fresh alveoli thetic success rate of 100%.

112
Discussion may serve as a surrogate for patients with poor
We found a nearly 96% implant survival rate vertical bone, as well as the difficult regions
among a consecutive series of 88 patients re- (95.2%), Table 1. We have only placed basal
ceiving 302 BOI® implants and fixed dentures implants in our practice during the observa-
with varying degrees of bone quality and quanti- tion period and therefore a direct comparison
ty. The only statistically significant factor on suc- to traditional root-form implant is not possible.
cess we found, is implant design (p<0.05). The This is a case series and can only be compared
survival rate in multiple disk implants (96.6%) to historical publications; however, our survival
is 1.7% higher than in those with single disk rates are very similar to those found in the lit-
(94.9%). This confirms clinical observations, be- erature.
cause multiple disks will be used in higher but The strengths of this study are many. Since we
narrow bone ridges, single disk implants when did not exclude any patients who presented to
vertical bone loss is extreme, so leverage differ- our clinic, even those send away by colleagues,
ences are obvious. Patients who received a sin- we feel that our findings are generalizeable.
gle crown had the lowest survival rate (90.9%; Even patients who typically may be turned down
p>0.05). Here were two failures among 22 im- due to poor bone quality or recommended to
plants, but these suffered from non-physiologi- receive bone augmentation procedures, are
cal, uncompensated forces. No other patient or smoking or show periodontal involvement are,
implant related characteristics were found to according to our findings, good candidates for
be associated with a failure rate over 7%. The basal implants. This is a consecutive series of
non-significant difference in bone status results patients and hence does not represent a conve-
brings a strong evidence for immediate placing nience sample or select group.
of basal implants. So even post extraction heal-
ing periods can be avoided. Diskimplants® are similar in form and func-
tion to BOI® implants and have reported rates
There are limitations to the present study. of successful osseointegration of ≥ 97% with
While we were all inclusive and did not turn any relatively long follow-up periods. Scortecci per-
patients away who desired implants, we did not formed a prospective case series of 783 im-
quantify bone quantity and quality. Had we done plants (627 Diskimplants®), placed in 72 pa-
this, we feel we would make an even stronger tients with completely edentulous maxillae using
case for the use of BOI® implants in patients an immediate load protocol. Follow-up ranged
with poor bone, Figures 3-5. However, we did from 6 – 48 months. At 6 months, 98% of im-
report a similar rate of survival among patients plants were osseointegrated, with all fixed pros-
who received single-disk implants (94.9%) ver- theses remaining functional during the study pe-
sus multi-disk implants (96.6%). Patients who riod.10 Scortecci combined crestal and basal
received single-disks generally had very little implants, which makes it difficult to distinguish
vertical bone available and therefore this group between the merits of basal and crestal implant

CMF.Impl.Dir. Vol 3-2007 113


designs. Our study shows that basal implants by as possible infections, malocclusions and surgi-
themselves are safe and effective. cal and prosthodontic mistakes. A similar result
is found in literature, where the secondary bone
Ihde and Mutter performed a retrospective loss like crater in crestal implants begins about
case series of 275 BOI® implants in 228 pa- eight years after implantation (19). Checkup of
tients over a period of five years. Molars were this cohort about ten years after implantation
replaced with BOI® implants in combination may bring significant findings regarding the im-
with natural abutments. Osseointegration was plant loss after functional use.
achieved in 254 implants at final follow-up. Fif-
teen implants were lost (11). This study shows Conclusion
that basal implants work well in combination The standard procedure for placing basal im-
with natural abutments. plants includes one surgery followed by immedi-
ate loading, thus reducing time, cost, and stress
Donsimoni et al performed a retrospective to the patient (10,14-17). With the emphasis
case series evaluating 1352 consecutive basal on lateral rather than vertical placement, pre-
implants placed over a 10 year period in 234 implantological bone augmentation was never
circular bridges (12). Osseointegration was necessary. Estimated decrease in cost treat-
achieved in 97%. Of the 41 implants that failed, ment time is ~ 50%16. There is no hospital res-
25 had to be replaced. Only one full upper bridge idence needed, no time period without proper
had to be permanently removed rendering a masticatory function, no second surgery. Com-
clinical success of 99.9%. Interestingly, smok- plications associated with basal implants are
ers and non-smokers experienced similar rates rare and have proven to be easy to handle. The
of implant losses. This may indicate that smok- clinical application of BOI® implants is safe and
ers, reported as having a higher risk of implant effective and useful in a broad range of indica-
loss in conventional implants (14), may benefit tions.
from BOI® implant treatment. Donsimoni et al
used only basal implants in their study, how-
ever they inserted a greater number of basal
implants per jaw (up to 12) compared to us (<=
8). Nevertheless the results presented in this
article match well with our findings.
The found missed influence of patient‘s age,
sex, and the time of placement of the implant
after tooth extraction correlated with Haas et
al (18).
The better survival rate in implants longer in
situ comes from their survival of initial threats

114
References

1. Gapski R, Wang HL, Mascarenhas P and Lang NP: Critical review of immediate implant loading. Clin Oral Implants Res. 14: 515-27, 2003.
2. Becker W, Hujoel PP, Becker BE and Willingham H: Osteoporosis and implant failure: an exploratory case-control study. J
Periodontol. 71: 625-31, 2000.
3. Blomqvist JE, Alberius P, Isaksson S, Linde A and Hansson BG: Factors in implant integration failure after bone grafting: an
osteometric and endocrinologic matched analysis. Int J Oral Maxillofac Surg. 25: 63-8, 1996.
4. Bryant SR and Zarb GA: Outcomes of implant prosthodontic treatment in older adults. J Can Dent Assoc. 68: 97-102, 2002.
5. Rocci A, Martignoni M and Gottlow J: Immediate loading of Branemark System TiUnite and machined-surface implants in the
posterior mandible: a randomized open-ended clinical trial. Clin Implant Dent Relat Res. 1: 57-63, 2003.
6. Truhlar RS, Morris HF and Ochi S: Implant surface coating and bone quality-related survival outcomes through 36 months
post-placement of root-form endosseous dental implants. Ann Periodontol. 5: 109-8, 2000.
7. Sanfilippo F and Bianchi AE: Osteoporosis: the effect on maxillary bone resorption and therapeutic possibilities by means of
implant prostheses--a literature review and clinical considerations. Int J Periodontics Restorative Dent. 23: 447-57, 2003.
8. von Wowern N: General and oral aspects of osteoporosis: a review. Clin Oral Investig. 5: 71-82, 2001.
9. Boyne PJ, Lilly LC, Marx RE, Moy PK, Nevins M, Spagnoli DB and Triplett RG: De Novo Bone induction by recombinant human
bone morphogenetic protein-2 (rhBMP-2) in maxillary sinus floor augmentation. J Oral Maxillofac Surg. 63: 1693-707, 2005.
10. Scortecci G: Immediate function of cortically anchored disk-design implants without bone augmentation in moderately to
severely resorbed completely edentulous maxillae. J Oral Implantol. 25: 70-9, 1999.
11. Ihde S and Mutter L: Versorgung von Freiend-Situationen mit basal osseointegrierten Implantaten (BOI) bei reduziertem ver
tikalen Knochenangebot. Dtsch Zahnärztl. Zeitschr. 58: 94-102, 2003.
12. Donsimoni JM, Dohan A, Gabrieff D and Dohan D: Les implants maxillofaciaux a plateaux dassise. Implantodontie. 13: 217-228, 2004.
13. Liran L and Schwartz-Arad D: The effects of cigarette smoking on dental implants and related surgery. Implant Dentistry. 14: 357-361, 2005.
14. Ihde SK: Fixed prosthodontics in skeletal Class III patients with partially edentulous jaws and age-related prognathism: the
basal osseointegration procedure. Implant Dent. 8: 241-6, 1999.
15. Ihde S: Restoration of the atrophied mandible using basal osseointegrated implants and fixed prosthetic superstructures.
Implant Dent. 10: 41-5, 2001.
16. Ihde S and Eber M: Case report: Restoration of edentulous mandible with 4 boi implants in an immediate load procedure.
Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 148: 195-8, 2004.
17. Ihde S: Principles of BOI. Springer Berlin Heidelberg New York ISBN 3-540-21665-0, 2005
18. Haas R, Mendorff-Pouilly N,Mailath G, Bernhard T: Five-year results of maxillary intramobile Zylinder implants. Br J Oral
Maxilofac Surg, 36,2,123-8, 1998
19. Ihde S, Konstantinovic V: Comparison and definition of the pathological phenomena occurring after a tooth replacement and
the possible therapeutic stages implying basal and crestal implants, Implantodontie, 14, 176-185, 2005

CMF.Impl.Dir. Vol 3-2007 115


Implants Implanted % Survival N % Sig.* p-value
Over all 302 100 289 95.7
Time in situ
30 days and more 297 98.3 284 95.6
60 days and more 266 88.1 255 95.9
90 days and more 253 83.8 143 96
180 days and more 252 83.4 242 96
1 year and more 197 65.2 190 96.4
2 year and more 103 34.1 101 98.1
3 year and more 49 16.2 49 100

Bonestatus (placed into) .671


Healed bone 145 48 138 95.2
Fresh alveoli: of teeth/implants 157 52 151 96.2
of implants only 20 6.6 20 100

Gender .139
Female patients 156 51.7 151 96.8
Male patients 146 48.3 138 94.5

Jaw .519
Upper jaw 162 53.6 154 95.1
Lower jaw 140 46.4 135 96.4

Localization .576
Sub nasal 29 9.6 29 100
Sub antral 76 25.2 71 93.4
Distal lower jaw 84 27.8 80 95.2

Summation difficult bone areas 189 62.6 180 95.2

Upper canine & 1st premolar 57 18.9 54 94.7


Between foramina in lower jaw 56 18.5 55 98.2

Summation difficult bone areas 113 37.4 109 96.5

Implant design .043


Single disks 156 51.7 148 94.9
Multiple disks 146 48.3 141 96.6

Shaft height in mm (range 3-11) .567


<8 82 27.2 78 95.1
=8 177 58.6 169 95.5
>8 43 14.2 42 97.7

Prosthetic class .350


Crown on implant 22 7.3 20 90.9
Segmental bridge on implants only 58 19.2 54 93.1
Bridge on implants with teeth 56 18.5 54 96.8
Circular bridge on implants only 166 55 161 97

Added by Nanobone® 12 4 12 100

Initially fixed by osseous fixation screw 6 2 6 100

Loaded immediately (within 24h) 301 99.7 289 95.7

*Log-rank test (Mantel-Cox)

116
Figure 1. Typical BOI® shapes representing single, double
and triple base-plate designs as well as three different supra
structure connectors as external thread connection, integrated Figure 2. Schematic drawing showing a typical basal implant
abutment and external octagon connector with internal screw after trans-osseous insertion in the distal mandible. This im-
(ITI-compatible). plant was inserted from the right side, achieving a bi-cortical
support.

Figure 3. A typical patient with congenital anodontia and there- Figure 4. This X-ray shows an exemplary male patient nine
fore a thin bone ridge is treated with BOI® in an immediate months post surgery, where five residual teeth and removable
loading protocol. The right 2nd incisor implant was primarily dentures were replaced with two bridges on eight BOI® in stra-
fixed by a osseous fixation screw. (Published with the patient’s tegic position. The atrophic distal jaws are excellent regions for
BOI®. (Published with the patient’s consent)

Figure 5. Open implant region nearly one year after Implantation.


The reopening was necessary, because the implants were bent for-
ward by artificial forces by this male patient, the osseointegration Figure 6. Kaplan-Meier survival curve for all implants in this
did not suffer any harm. Two BOI®s were added between the exis- consecutive case series.
tent ones and a new bridge was fixed. (Published with the patient’s
consent)

CMF.Impl.Dir. Vol 3-2007 117


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118